Provider Demographics
NPI:1679639702
Name:COOPER-JENNINGS, STACEY M (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:M
Last Name:COOPER-JENNINGS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:74 PACKERS FALLS RD
Mailing Address - Street 2:
Mailing Address - City:NEWMARKET
Mailing Address - State:NH
Mailing Address - Zip Code:03857-1008
Mailing Address - Country:US
Mailing Address - Phone:603-659-6137
Mailing Address - Fax:
Practice Address - Street 1:60 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6207
Practice Address - Country:US
Practice Address - Phone:978-373-1126
Practice Address - Fax:978-373-6363
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110981041C0700X
NH10981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1312294Medicaid
MAP22598Medicare ID - Type Unspecified